Richard M. Fairbanks School of Public Health Theses and Dissertations
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Item Sexually Transmitted Infection Testing Adherence Among Pregnant Women(2026-03) Ho, Yenling Andrew; Dixon, Brian E.; Blackburn, Justin; Duszynski, Thomas J.; Han, JialiPrenatal screening and treatment of sexually transmitted infections (STIs) are critical components of maternal and child health, as they play a vital role in preventing adverse birth outcomes. Despite the Centers for Disease Control and Prevention (CDC) publishing regular guidelines for prenatal STI screening and treatment, limited evidence exists regarding provider adherence to these recommendations as the majority prior studies rely on public health case reports or manual chart reviews, which restrict scalability and generalizability. Administrative health data, particularly International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes, offer a promising avenue for large-scale epidemiologic surveillance of pregnancy-related exposures and outcomes. These codes can capture key clinical details, including gestational age and delivery outcomes, which are essential for assessing guideline adherence. However, the validity of gestational ICD-10-CM codes in accurately identifying gestational age at the time of diagnosis remains uncertain. This dissertation leverages linked electronic health records from the Indiana Network for Patient Care and the state birth registry to address three aims: 1) evaluate the accuracy of gestational age-related ICD-10-CM codes in identifying pregnancy trimester and gestational weeks; 2) assess provider adherence to CDC syphilis screening guidelines among stillbirth cases; and 3) evaluate adherence to CDC guidelines for chlamydia and gonorrhea screening during pregnancy. Findings from this research will inform public health strategies to improve prenatal STI screening practices and enhance maternal and child health outcomes.Item Examining the Role of Value-Based Care Transitions in Reducing Primary Care Clinician Burnout(2026-05) Cheek, Annie Nicole; Tierney, William M.; Callahan, Christopher M.; Coburn, Kenneth; de Groot, MaryObjective: To explore how value-based care frameworks can reduce clinician burnout and how the implementation of these frameworks can best support clinician resilience and sustainable care delivery. Methods: This qualitative study involved semi-structured key informant interviews with 23 primary care stakeholders (physicians, mid-level leaders, and senior executives) from Indiana University Health, a large academic health system. Data was collected between November and December 2025. Transcripts were analyzed using inductive thematic analysis in ATLAS.ti to identify emergent themes, with Google Gemini employed as a supplementary tool for confirmatory review. Principal Findings: The study reveals a critical “Alignment-Execution Gap.” While clinicians demonstrate high “value alignment” with value-based care (VBC) philosophy, this intrinsic motivation is neutralized by “metric fatigue” and administrative burden. Resistance is operational rather than ideological; clinicians support the mission but reject the method when metrics are experienced as bureaucratic “box-checking” rather than clinical aids. The study finds that value-based care fails as a burnout intervention when implemented as an “additive” layer to fee-for-service tasks. Successful transition requires “subtractive” measures – specifically “administrative relief” – and the adoption of “team-based care” to restore professional autonomy and cognitive capacity. Conclusion: The primary barrier to value-based care adoption is not a lack of buy-in, but a failure of execution. The “why” is sold, but the “how” is broken. Wellness initiatives cannot compensate for broken workflows; the most effective intervention is the repair of daily operations to demonstrate respect for clinician time. Sustainable transition requires shifting from compliance-based management to a “change leadership” framework (e.g., Kotter and Bridges) that prioritizes upfront resource allocation, transparency, and communication to bridge the disconnect between executive strategy and frontline reality.Item The Cost and Management of Chronic Pain(2026-01) McCord, Emma Marie; Mazurenko, Olena; Blackburn, Justin; Harle, Christopher A.; Holmes, Ann M.Chronic pain is a significant public health problem in the United States, affecting more than 50 million adults. It ranks among the costliest chronic health conditions due to high healthcare utilization, disability rates, and lost worker productivity. Most patients with chronic pain are managed in primary care. Yet, primary care clinicians face significant barriers when managing patients with chronic pain, as they navigate patients’ multifaceted pain histories under time constraints. Digital health technology, such as clinical decision support (CDS) systems can provide PCCs with relevant patient information through streamlined workflows to improve care, yet they are often underutilized. At the same time, there is a lack of evidence on the national incremental healthcare costs of chronic pain, making it challenging to allocate limited healthcare resources effectively. Thus, there is a significant need for evidence to guide both economic and digital health technology strategies to improve pain care for millions of adults with chronic pain. This dissertation addresses critical gaps in the cost and CDS system management of chronic pain by: 1) estimating the incremental annual healthcare costs associated with chronic pain using nationally representative data; 2) examining how primary care clinician characteristics moderate the relationship between patient encounter characteristics and CDS system use; and (3) evaluating the effect of CDS use at a patient encounter on guideline-recommended chronic pain management. Findings from the cost analysis can help policymakers and health systems more accurately target investments in chronic pain care and assess the value of intervention strategies. Findings from studies on CDS system use provide actionable insights to inform the design, targeting, and implementation of digital health technologies that enable more efficient, evidence-based care for patients with chronic pain.Item Leadership Developments for Effective Implementation of Universal Health Coverage in North West Province of South Africa(2025-09) Kuwane, Bulelani; Babich, Suzanne; Czabanowska, Katarzyna; Setswe, GeoffreyThe research explored how best to develop leadership competencies amongst health leaders to support successful implementation of Universal Health Coverage (UHC) in the North West Province of South Africa (SA). SA will implement UHC through the National Health Insurance (NHI). The aim of the research study was to explore how best can leadership competencies be developed in the public health workforce to effectively implement UHC. The objectives were, a) Describe current health leadership competencies needed to advance the implementation of Universal Health Coverage in South Africa. b) Identify barriers and facilitators to health leadership in South Africa. c) Develop an effective leadership development model for the implementation of Universal Health Coverage in the North West province of South Africa. The research study was qualitative study using a non-experimental, descriptive design methodology. The data were gathered through key informant interviews with healthcare leaders using MS Teams. Interviews were recorded and transcribed. Data were analysed by looking at themes and patterns using NVivo system. The findings of the research showed that strategic vision and planning, openness to mentorship and learning, effective decision-making, reassurance and confidence building, vulnerability and emotional intelligence, collaborative leadership, advocacy and influencing, budgeting and resource allocation. accountability in financial practices are important leadership competencies for implementation of UHC. The research showed that mentorship, peer support, international partnerships and training programs are facilitators of leadership development. Structured leadership programs, continuous professional development, advocacy for leadership support and de-politicising appointments were recommended strategies for leadership development. This study emphasized the critical need for resilient and flexible leadership in response to evolving problems in SA's healthcare sector. There is an urgent demand for leaders in health to be not only technically sound but also emotionally intelligent, strategically savvy, and operationally capable enough to thrive in complex policy and resource environments.Item How Can a CRO-Specific Leadership Framework be Developed to Enhance the Effectiveness and Efficiency of CRO Leaders in Managing Clinical Trials?(2025-11) Li, Jianrong; Nan, Hongmei; Han, Jiali; Anderson, Randy L.The high cost of medicine in the U.S. presents a critical public health challenge, limiting the accessibility and affordability of essential treatments. While many factors influence drug pricing, reducing development costs through efficient CRO operations and effective leadership can support more competitive pricing and improved access. This project aimed to establish a CRO-specific Leadership Framework by conducting interviews with seasoned CRO leaders and leaders from Pharma and Biotech companies to capture insights and best practices. A qualitative research approach was adopted to explore the traits, expertise, and characteristics that define successful CRO leadership. Semi-structured interviews were conducted, recorded, transcribed, and analyzed using thematic analysis with Quirkos software. The study resulted in the development of a CRO-specific Leadership Framework that identifies six REAJIA traits - Resilience, Empathy, Adaptability, Judgment, Integrity, and Acumen - mapped to externally observable leadership behaviors. In addition, the “Leadership Wheel” was created to illustrate how these traits interconnect dynamically to drive effectiveness in CRO environments. Together, these tools provide a structured approach for understanding and cultivating leadership that balances operational efficiency, sponsor satisfaction, and team performance. This project contributes to both academic and practical discussions on leadership in clinical research. The framework and leadership wheel offer CROs and sponsors a foundation for leadership assessment, development, and evaluation. By clarifying the traits and behaviors most critical in CRO contexts, the study highlights leadership’s central role in improving efficiency, strengthening collaboration, and supporting more sustainable drug development practices. Future research should focus on quantitatively validating the framework, testing cross-cultural applicability, and incorporating emerging competencies such as digital leadership to reflect innovations in clinical trials.Item Analyzing the Association of COVID-19 Vaccination with Changes Among Individuals with Diabetes and Obesity: A Retrospective Cohort Analysis Among Indianapolis Metropolitan Residents(2025-12) Hanley, Shane M.; Han, Jiali; Dixon, Brian E.; Duszynski, Thomas J.; Grannis, ShaunIntroduction: The COVID-19 pandemic was detrimental in a multitude of aspects of health. One specific area of research that was touched on but not to a greater extent was the impact of the COVID-19 pandemic on the clinical visits for those with other comorbidities. In relation to this dissertation, the focus is to highlight the impact COVID-19 vaccines had on A1C levels and weight before and after vaccine availability. Methods: A retrospective cohort was designed by selecting residents from Indianapolis metropolitan hospitals who were diagnosed with diabetes or obesity prior to January of 2019. The study period began in 2019 right before the COVID-19 pandemic and ended in December of 2022. Descriptive statistics were computed to display the difference in proportions of all covariates by vaccine status. Multiple logistic regression was conducted to test for the potential association between those who were vaccinated and lower on average AIC level or average weight in kilograms by end of study compared to those not vaccinated. Separate confounding and interaction testing were conducted as well on all other covariates individually with vaccine status. Results: Those that were not vaccinated had a 0.11 greater AIC level by end of study compared to those that were vaccinated and while controlling for all other covariates was still 0.29 with the largest statistically significant confounder being diabetes at 0.30. Those that were not vaccinated had a 4.04 kilograms greater average weight by end of study compared to those that were vaccinated and while controlling for all other covariates was still 0.92 kilograms heavier among the non-diabetic group. Those that were not vaccinated had a 6.36-kilogram greater average weight by end of study compared to those that were vaccinated and while controlling for all other covariates was still 3.40 kilograms heavier among the diabetic group. Conclusion: This study helps quantify the relationship between COVID vaccine status and A1C/weight management. More research is warranted to further observe these health outcomes beyond the height of the pandemic.Item Evaluating Multi-Cancer Early Detection (MCED) in Medicare: Cost-Effectiveness and Policy Pathways for Pancreatic Cancer(2025-12) Raygoza, Adrian Ignacio; Han, Jiali; Reina Ortiz, Miguel; Reed, Steven B.Pancreatic ductal adenocarcinoma (PDAC) is one of the most lethal cancers. Most patients enter the clinical pathway at an advanced stage, long after symptoms have appeared, which limits treatment options and survival. Multi-Cancer Early Detection (MCED) tests that examine methylation patterns in circulating cell-free DNA offer a possible route toward earlier, more actionable diagnoses. Even with that promise, questions remain about the true economic value of these tests and the feasibility of Medicare coverage for the populations that may need them most. This dissertation used a convergent parallel mixed-methods design to examine these questions. The quantitative analysis relied on a patient-level microsimulation built from nine confirmed Stage II and III PDAC cases, each supported by real-world billing data. The model was expanded through 30,000 Monte Carlo replications to test stability and ranges of possible outcomes. The average cost per patient was $177,691. When applied to the 67,440 projected incident PDAC cases in 2025, this produced a conservative lower-bound estimate of about $12.0 billion in national direct medical spending. Stage-weighted modeling showed that most of these costs come from distant-stage disease, which accounts for more than three-quarters of total spending. When adjusted to the share of Medicare beneficiaries, the estimated Medicare-attributable spending ranged from $7.2 to $9.6 billion each year. The qualitative analysis examined eight elite interviews with congressional staff conducted between February and July 2025. By the eighth interview, thematic saturation had been reached, producing 21 themes across fiscal, clinical, and policy areas. Staff from both parties raised persistent concerns about Medicare solvency and emphasized the need for strong fiscal safeguards in any new coverage pathway. PDAC was viewed as a compelling application for MCED because of its severity, limited early detection options, and the high costs associated with late-stage care. Across offices, Coverage with Evidence Development (CED) emerged as a feasible policy pathway, supported by constituent stories and earlier precedents in colorectal screening tools. Convergent integration of the two strands demonstrated how the cost modeling and policy perspectives align. Both strands identified Stage III PDAC as a major source of economic and clinical burden, and congressional staff viewed feasibility through the lens of Medicare solvency and patient access. CED appeared as a shared mechanism that could balance early innovation with careful fiscal oversight. Bringing together health economics and elite interviewing illustrated how policy feasibility can be assessed in a practical way. The findings suggest that MCED for PDAC may be both economically and politically feasible when directed toward high-risk populations within a Medicare CED pathway, creating an opportunity to support earlier detection in a cancer that remains one of the most urgent challenges.Item Studies Examining Maternal Vaccination Decisions and Influenza Burden in U.S. Infants Ages 0-5 Months(2025-11) Albertin, Christina Susanne; Dixon, Brian; Duszynski, Thomas; Zimet, Greg; Turman, Jack E.Introduction Pregnant women and young infants are particularly vulnerable to respiratory viral infections, but infants aged 0-5 months cannot receive COVID-19 and influenza vaccines, making maternal vaccination a key prevention strategy. We examined changes in rates of maternal COVID-19 and influenza vaccination, influenza-associated hospitalization burden and characteristics of influenza positive infants aged 0-5 months by acute care setting. Methods Data from two health systems and a surveillance network were analyzed. Study 1 examined COVID-19 and influenza vaccination patterns between two temporal cohorts of pregnant women (2021-2023, n=5,949). Study 2 compared characteristics of influenza-positive and influenza-negative hospitalized infants aged 0-5 months and calculated an influenza hospitalization rate for this age group from 2016-2020 (n=2,605). Study 3 compared infants with laboratory-confirmed influenza discharged from the emergency department versus hospitalized (n=210). Results In Study 1, COVID-19 vaccinations fell substantially between the two cohorts (62% to 26%), while influenza vaccination showed a lesser decline (52% vs 48%). Those receiving neither vaccine increased (26% to 44%). Study 2 found influenza-positive infants had less severe illness than influenza negative infants, 79% of whom tested positive for other viral pathogens. The calculated influenza hospitalization rate was 129.5 per 100,000 infants. Study 3 identified younger age and underlying condition as associated with hospitalization (aOR 4.37, 95% CI 2.11-9.06, aOR 6.29, 95% CI 2.34-16.86). Public insurance and higher maternal education had lower odds (aOR 0.12, 95% CI 0.04-0.34), aOR 0.36, 95% CI 0.14-0.91). Conclusion Our calculated influenza hospitalization rate (2016-2020) was significantly lower than historical estimates from the 2000s, coinciding temporally with increased national maternal influenza vaccination coverage. Our analysis of influenza among infants aged 0-5 months demonstrated that influenza comprised a small proportion of acute respiratory illness hospitalizations. Maternal vaccination patterns revealed declines in uptake of both vaccines between 2021-2023, with COVID-19 vaccination showing the steepest decrease. Considering recent national declines in maternal influenza vaccination, our findings underscore the importance of developing targeted interventions to improve maternal vaccination coverage and sustain reduced influenza hospitalization burden in this age group.Item Medicaid Continuous Eligibility and its Associations with Administrative Costs, Unmet Needs, and Health Service Utilization(2025-10) Tran, Yvette Ho; Blackburn, Justin; Holmes, Ann M.; Vest, Joshua R.; McFarlane, Timothy D.Medicaid acts as a vital safety net in the United States—providing health insurance for households with limited income, seniors needing long-term care services, and persons with disabilities. However, income fluctuations and unsuccessful Medicaid renewals result in transient lapses in coverage for some enrollees, otherwise known as churn. Prior studies have estimated that around eight percent of enrollees experience churn within a year. Enrollees experiencing churn may be more likely to delay or forgo preventive care, potentially leading to adverse health outcomes and higher healthcare costs downstream. Policies such as implementing ex parte renewals or reducing the number of eligibility checks conducted each year have helped to reduce, but not eliminate, churn. In March of 2020, the United States Congress passed the Families First Coronavirus Response Act, which introduced maintenance of effort (MOE) requirements in exchange for enhanced federal funding to states. To comply with MOE requirements, states ensured enrollees had continuous eligibility throughout the public health emergency period, which spanned March 2020 through March 2023, regardless of changes in financial circumstances. This policy temporarily eliminated almost all churn and contributed to record high Medicaid enrollment, but its consequences for administrative cost, unmet healthcare needs, and service utilization are unclear. The purpose of this dissertation is to assess the relationship between continuous eligibility policy and 1) administrative costs; 2) unmet medical, dental, and prescription medication needs; and 3) health service utilization. This dissertation includes three studies: 1) a pre-post analysis of state-year panel data that assesses trends in overall, per-enrollee and per capita administrative spending; 2) a difference-in-difference with inverse probability weights analysis that examines the relationship between churn and unmet medical, dental, and prescription medicine needs; and 3) a comparative interrupted time series study that compares changes in well-child, preventive dental, office-based, emergency department, and hospital encounters by history of churn. With Medicaid consuming about eight percent of federal and 30 percent of state budgets, respectively, policymakers have and will consider Medicaid financing reform, benefits redesign, and innovations in eligibility and renewal policies. Evidence from this dissertation will help inform policymakers about the tradeoffs of various decisions and priorities.Item Barriers to Trust in the Utilization of Health-Related Social Needs Data from the Electronic Health Record(2025-08) Allen, Katie Sue; Vest, Joshua R.; Blackburn, Justin; Dixon, Brian; Yeager, ValerieAddressing health-related social needs (HRSN)—such as food insecurity, housing instability, transportation barriers, and financial strain—is increasingly recognized as essential to achieving equitable health outcomes. These factors play a critical role in shaping patients’ health risks, care access, and health outcomes. Consequently, understanding and addressing HRSN is vital to both clinical decision-making and population health management. The electronic health record (EHR) holds promise as a tool for the systematic collection and use of HRSN data. However, current practices are marked by inconsistencies and limited adoption of structured coding systems. Highquality, standardized data are critical for the meaningful application of HRSN information, yet multiple barriers hinder collection. These challenges are not solely technical. Patients may be reluctant to disclose sensitive social information, and clinicians may feel discomfort or uncertainty about asking, recording, or acting on such data. These attitudinal and structural obstacles introduce the potential for bias in EHRderived data, which may compromise the fairness and effectiveness of downstream applications. If unaddressed, these limitations may undermine trust in the utility and accuracy of EHR-based social factors data. This dissertation investigates the structural and attitudinal factors that influence trust in EHR-derived HRSN data, with a focus on data quality, documentation practices, and clinician perspectives. First, it evaluates the robustness of EHR-based HRSN data by comparing prevalence estimates derived from structured fields with external community benchmarks. Discrepancies highlight areas where under-documentation or misrepresentation may occur. Second, the study examines demographic and system-level characteristics associated with whether patients’ social needs are captured in the EHR, identifying patterns that may reflect disparities in documentation. Third, semi-structured interviews with clinicians provide qualitative insight into their experiences documenting HRSN, their trust in the data’s accuracy, and their perceptions of its role in clinical care. Together, these mixed-methods investigations offer a comprehensive understanding of the barriers and facilitators to trustworthy and equitable use of HRSN data within EHRs. Findings will inform future strategies to strengthen data quality, enhance clinician engagement, and ensure that EHR-derived social factors data can be reliably leveraged to support health equity and improved patient outcomes.